What is the role of dual antiplatelet therapy (DAPT) for intracranial arterial stenosis?

From the Guidelines

Dual antiplatelet therapy (DAPT) is not recommended over single antiplatelet therapy (SAPT) for patients with intracranial arterial stenosis, unless there are other indications for DAPT. The most recent and highest quality study, a systematic review and synthesis of global stroke guidelines published in the International Journal of Stroke in 2023 1, found that there are no strong recommendations supporting the use of DAPT over SAPT in this population.

Key Points

• The use of anticoagulants is not recommended in patients with acute ischemic stroke or transient ischemic attack (TIA) due to high-grade intracranial atherosclerotic disease, unless there is another indication for anticoagulation 1.
• Single antiplatelet therapy, typically aspirin 325 mg daily, is recommended over oral anticoagulation for patients with ischemic stroke or TIA caused by moderate to high-grade intracranial atherosclerotic stenosis (50-99%) 1.
• The SAMMPRIS trial showed that DAPT is better than stenting, but it did not prove that DAPT is better than SAPT 1.
• A post-hoc analysis of the CHANCE trial showed no differences in the beneficial effect of DAPT vs SAPT in minor stroke patients with vs without intracranial atherosclerotic disease 1.

Management

• Aggressive medical therapy, including blood pressure management, lipid-lowering medications, and diabetes control, is recommended for patients with ischemic stroke or TIA and intracranial atherosclerotic disease 1.
• A systolic blood pressure target of <140 mmHg is recommended for patients with ischemic stroke or TIA caused by moderate to high-grade intracranial atherosclerotic stenosis (50-99%) 1.
• High-dose statin therapy is recommended for patients with ischemic stroke or TIA caused by moderate to high-grade intracranial atherosclerotic stenosis (50-99%) 1.

From the Research

Role of Dual Antiplatelet Therapy (DAPT) for Intracranial Arterial Stenosis

The use of DAPT for intracranial arterial stenosis has been studied in several research papers. Key findings include:

• DAPT using cilostazol was superior to single antiplatelet therapy (SAPT) with clopidogrel or aspirin for the prevention of recurrent stroke and vascular events without increasing bleeding risk among patients with intracranial arterial stenosis after stroke 2.
• An early aggressive risk factor modification program, which included DAPT with aspirin plus clopidogrel, was effective for the prevention of recurrent vascular events in patients with symptomatic intracranial stenosis 3.
• Combination therapy with clopidogrel and aspirin was more effective than aspirin alone in reducing microembolic signals in patients with predominantly intracranial symptomatic stenosis 4.

Benefits and Risks of DAPT

The benefits and risks of DAPT for intracranial arterial stenosis are:

• Reduced risk of ischemic stroke and composite of stroke, myocardial infarction, and vascular death 2.
• No significant increase in the risk of severe or life-threatening bleeding 2.
• Potential for increased risk of major bleeding, particularly when treatment is extended for greater than 30 days 5.

Recommendations for DAPT Use

Recommendations for the use of DAPT for intracranial arterial stenosis include:

• Aggressive medical management in addition to DAPT up to 90 days is recommended for patients with symptomatic intracranial stenosis 5.
• DAPT should be individualized based on the stroke characteristics, time from symptom onset, and patient-specific predisposition to develop hemorrhagic complications 5.
• Medical management, consisting of aggressive risk factor control and DAPT, is superior to angioplasty and stenting for the prevention of future stroke 6.